APPOINTMENT OF HONORARY RESEARCH ASSOCIATE APPLICATION FORM

APPLICANT’S DETAILS
Name
Organisation/Department
Email Address / Phone Number
PROJECT DETAILS
Project Title
Role in Project
HREC Approval / Pending / Approved
HREC Reference Number
In submitting this application form I affirm that:
1. / I have read and agree to comply with the conditions of HREC approval and the specific requirements of the SESLHD site authorization to conduct the project.
2. / I understand that this appointment is for the purpose of conducting this project and is only valid with a current Human Research Ethics Committee approval.
3. / I have read and understood the NSW Ministry of Health Code of Conduct and agree to abide by the provisions set out in this Code in relation to my involvement in this project for the purposes of which I have been offered this appointment.
4. / I am familiar with and agree to comply with the principles of the Australian Code for the Responsible Conduct of Research and the National Statement on Ethical Conduct in Human Research.
5. / I understand that I will have access to confidential data which will include the identity of, and personal and medical information on, individual persons.
6. / I undertake to preserve the confidentiality of these data. I will not use identified or potentially-identifiable data collected for the purpose of this project for any other purpose, or supply it to any third party, without the consent of the individual to whom the data relates, the approval of the Data Custodian and the approval of a properly constituted Ethics Committee.
7. / I have been informed of, willmake myself familiar with and agree to observe theLaws, Rules, Regulations, Policies and Procedures of the NSW Ministry of Health and the SESLHD relevant to my involvement in this project.
8. / I agree to attend any mandatory training as required by SESLHD.
9. / I understand that the SESLHD reserves the right to withdraw this offer of appointment if I fail to meet the above requirements.
10. / In the event of my resignation or termination from my honorary status at SESLHD, I will return any hospital property provided to me (i.e. ID Badge, keys etc.).
Signature of applicant: / Date:
SESLHD COLLABORATING CLINICIAN/SUPERVISOR
Name
Department/Site
Contact Details
I have discussed the project with the applicant and agree to the role as Collaborator / Supervisor
Signature of SESLHD Clinician / Supervisor / Date / / /
Confirmation of Support from SESLHDHead of Department
Name
Department/Site
Contact Details
I have reviewed this application in line with SESLHD OPS PROC – Appointment of Honorary ResearchAssociate and confirm the necessary documents have been provided and I support this application.
Signature / Date / / /
ONCE THE ABOVE SIGNATURES HAVE BEEN OBTAINED PLEASE FORWARD THIS APPLICATION, ALONG WITH ALL DOCUMENTS LISTED IN THE CHECKLIST BELOWTO THE SESLHD RESEARCH SUPPORT OFFICE FOR PROCESSING FOR APPROVAL.
SESLHD RESEARCH SUPPORT OFFICE
G71, EAST WING
EDMUND BLACKET BUILDING
PRINCE OF WALES HOSPITAL
Telephone: 9382 3587
Approval from Director of Operations
Name
Signature / Date / / /
Document Checklist
Completed and signed Application Form
A copy of the Applicant’s Curriculum Vitae
Certified Copy of Qualifications/Registrations (if applicable)
Proof of Identification (100 points)
Completed Criminal Record Check form
Working with Children Declaration (if required)
Details of Immunisation status (if required)
Evidence of Indemnity and Insurance cover
Signed NSW Health Code of Conduct (PD2012_018 – page 9)

SESLHD OPS REVISION 0 May 2013Page 1 of 2